Jane K. Dolan, RN
I remember one summer, sometime in my late 20’s, looking at the back of my calf and seeing something that appeared different. I reluctantly hauled myself off to the dermatologist. I am a dermatologist’s dream: fair skin, freckles, moles, spots, dots, and who-knows-what?
The appointment was to the point--the best way to know what this “different“ appearance in my skin would be done through a punch biopsy, and I consented. I can’t recall much about it, other than it reminded me of the drill attachment to make a hole for a doorknob. Basically, the punch had sharp teeth that rotated through the skin to take a core sample. With the help of a microscope, it would reveal how serious this was.
How Dangerous was my Biopsy?
When I returned to the dermatologist, I waited to hear the jury verdict. Was I going to live or die?
She said it is a basal-cell carcinoma--I heard carcinoma. Carcinoma means cancer, and YES, I was going to die. Bracing myself, she relaxingly said, “basal cells have a hard time reorganizing themselves after they have been disrupted. The punch biopsy should have done the trick.”
Okay…that was a buzzkill for the drama I had created in my mind. Yet happily I put the report in my mental file, and also in my filing cabinet, and carried on.
Maybe I should have mentioned that I am a nurse. Yet I did not go the path of dermatology. I went on to specialize in orthopedic and cardiac rehab. I spent 17 years there before I switched gears.
My next chapter in my nursing career brought me to primary care. It was quite different from my previous life of helping people recover from serious traumatic injuries, and cardiac events. In primary care, people would come in for yearly physicals or for follow-up to inpatient stays or outpatient procedures.
Soon enough, I saw the wounded warriors come in with horrific wounds on their body, yet mostly their face. Horrified, I asked what their course had been. Startlingly, I heard them say that they had a basal cell carcinoma, or rarely squamous cell carcinoma, and had to have a Mohs procedure. (Silently I retreated…Can you repeat that please? I think I may have missed something...)
This Mohs procedure was worlds apart from the punch biopsy I had. I am not sure I could even find that scar today. In juxtaposition, our patients looked as though they met up with Jason…you know, the horror-film-massacre-guy.
I doubted myself, my memory…it had been at least 20 years since my visit when I thought I had the same diagnosis when I followed a VERY different course.
At some point I reached a tipping point and dug through my files to see if I had confused my past recollection. Yet in finding my file, it confirmed my memory. What the heck? Why was I still alive? Why were these people butchered?
Basal cell cancer originates in the lowest layer of the skin whereas squamous cell cancer starts in the top layer of the skin. A Mohs procedure cuts out all possible margins of any possible cancerous lesions. While this approach embodies prudence, it also bears the potential to yield unsightly scars, disproportionate to the threat they address. Furthermore, these scars substantially elevate the risk of melanoma, a distinct and more alarming form of skin cancer that demands a different level of attention and treatment.1
So what is the TRUTH?
If you have ever attended a magic show, the grip it holds on you comes from not knowing how the magic is performed. Grasping the intricacies behind the magic dispels the illusion, making you immune to its spell.
In a similar vein, life's complexities often lie in the finer details. Roughly 2,000 individuals succumb to basal cell or squamous cell cancers annually, with a higher incidence among the elderly and those with compromised immune systems. 2 Despite this, the mortality rate remains notably low.
Yet, imagine for one moment you have a loved one who died from a basal cell carcinoma. If, in retrospect, a dermatologist could make the case that your loved one may have been saved if all the margins were removed, you may be moved into thinking this is how it should have been done. In essence, this single case, or a few resembling cases, can shape future protocols and practices.
Contemplate a situation where your doctor recommends amputation of your finger, hand, or arm every time you have a minor hangnail. From my journey, this feels comparable to the overly cautious approach in many Mohs surgeries.
One of the most formidable challenges lies in the unshakable conviction that doctors cultivate throughout their training journey. Having invested 8-10 years in absorbing and adopting what they perceive as the latest, meticulously verified knowledge, the prospect of veering from this path becomes a formidable mental hurdle, often entailing an arduous struggle to confront the dissonance in their beliefs. Regrettably, knowing that deviating from this model will take away their livelihood, a dynamic may result in unfavorable consequences for patients.
Patients who undergo Mohs procedures often express gratitude during follow-up exams, believing they have taken a drastic step to avert the perceived risk of imminent death. It's worth pondering whether these patients would still choose the same path if they were provided with comprehensive information regarding the trade-off between risk and benefit.
Furthermore, in examining the literature, punch biopsies are now strictly diagnostic, sadly making this option unavailable.
If you are at risk and are wondering what you can do to possibly reduce the occurrence of basal cell carcinoma and cutaneous squamous cell carcinoma it is worth looking into oral niacinamide (nicotinamide).3